Losing Sleep Over It

The “slumbering giant” of the United States has awakened, all right. But now many of us can’t get back to sleep.

In the days after Sept. 11, 44% of Americans reported trouble falling asleep, 48% said they had more awakenings, and 50% said they woke up unrefreshed, according to a nationwide survey released last week by the National Sleep Foundation. A spot survey by the Pew Research Center after the attacks put the rate of sleep problems at 33%--about the number of Americans who typically report having insomnia symptoms over a given year. Under typical circumstances, these difficulties would resolve quickly, researchers have found.

But there is nothing typical about this season, sleep doctors said: The simmering stew of terrorism, war, job cuts and holiday stress has tormented poor sleepers and spoiled nights for many across the country.

“I wasn’t sleeping very well before September, and 9-11 sure didn’t help,” said Constance Ebright, 66, a travel agent in Glendale, who began seeing a sleep specialist this month. “I specialize in trips to Africa. Needless to say, no one’s all that eager to fly to Africa these days.”

Dr. Clete Kushida, director of the Stanford University Center for Human Sleep Research in Palo Alto, said the Silicon Valley isn’t sleeping so well either. “Because of the fallout in the computer industry, I can tell you, we are seeing a lot more patients in the last couple of months. People are putting in long hours at work. They’re worried about losing their jobs, and their sleep problems have worsened.”

That’s the riddle of insomnia. While most of us return to normal after one or two restless nights, there are anywhere between 5 million and 10 million Americans who do not. Their bodies somehow fail to reclaim the one commodity they need most, slumber, even as they become more exhausted and desperate. Part of the underlying problem may be mental; doctors have long known, for instance, that chronic sleeplessness is linked to psychological distress, such as depression and anxiety.

Sleep researchers now are finding evidence that nagging sleep problems are often due to measurable, physical differences. “One of the common misconceptions about insomniacs is that they’re all crazy, depressed or anxious, and I think this message just upsets those who have problems sleeping,” said Michael Bonnet, a sleep researcher at Wright State School of Medicine in Dayton, Ohio. “But what we’re discovering now is that a lot of them have an underlying physical disorder that makes them more prone” to restless nights.

Sleep problems tend to progress in a familiar pattern, doctors said. First, comes a trigger--an argument with a spouse, an important speech or test, a bad cold, a 9-11 flashback--that ruins a night’s sleep. “The next night is often just as bad because in the back of our minds, we’re thinking, ‘Oh, no, I had a lousy night. I’d better sleep well tonight,’” said Dr. Daniel Buysse, a sleep researcher at the University of Pittsburgh. The pressure itself interferes with sleep--and the pattern is repeated night after night.

That’s usually when people begin to change their behavior. “People hit the alcohol first, then they hit the drugstore, then they start spending more time in bed--and all of this only makes the problem worse,” said Dr. Joyce Walsleben, director of the New York University Sleep Disorder Center. “That’s when they go see their primary care doctors--and eventually make their way to me.”

For a string of bad nights to degenerate into a chronic problem, though, many researchers believe that there must also be a predisposition to insomnia--a physical sensitivity to sleep loss. The evidence for this comes from a scattering of experiments, all of which show signs of elevated nervous system agitation in insomniacs. In a study published this fall, for instance, researchers at Penn State University reported that blood levels of so-called stress hormones, such as cortisol, were significantly higher in insomniacs than in healthy sleepers. “These are very necessary hormones, but they promote wakefulness, alertness,” says Dr. Alexandros Vgontzas, one of the study’s authors. And while the insomniacs’ levels were elevated all day long, they were especially high in the evening and early nighttime.

Vgontzas said the elevated hormone levels precede the insomnia. “We know from earlier studies that depriving people of sleep does not drive their cortisol levels up like this; they begin with the higher levels.”

Compared with normal sleepers, insomniacs tend to have a faster metabolism, recent work by Bonnet has found. They seem to have elevated body temperature when they fall asleep, compared with sound sleepers, studies suggest. Their heart rates are often higher. And in lab studies, they’re better able than normal sleepers to recall noises and sounds during their sleep, according to University of Arizona research. All of these arrows point in the same direction, said Bonnet: to a group of people whose central nervous system slightly favors alertness over sleep.

“I think of it as an innate state of hyper arousal,” he said. “You take a group of 100 people, and you are going to find a few people who have this alert state, just like you’ll find some tall people and some short people. The poster boy for this condition is Don Knotts on the old ‘Andy Griffith Show’”--nervous, jittery, bug-eyed. In 1998, Bonnet conducted experiments to determine how sleep-deprived insomniacs must be before they can actually nap in the same way normal sleepers do when exhausted. “We had to interrupt their sleep continually, so they were getting only about 41/2hours a night, before we found that they could lie down and get themselves to sleep as quickly as normal sleepers,” he said. “That tells me that these people are fighting against a nervous system that is hyper aroused.”

This is one reason why insomnia is so hard to treat. Doctors now prescribe a wide spectrum of drugs, from sleeping pills to antidepressants, to help resolve chronic sleep problems. For severe insomniacs especially, these therapies are crucial; without some pharmaceutical sleeping aid, many could not function. But many of these medications can cause daytime grogginess, without altering the body’s underlying inability to rest.

Most doctors who treat sleep problems now put a heavy emphasis on behavioral changes that help patients counter their native physical nervous arousal. These include familiar cautions against caffeine, alcohol and nicotine in the evening; and an emphasis on a sleep routine. Make the bedroom as dark and quiet as possible; use the bed for sex and sleeping only; and get up at the same time every day.

“The idea is to focus on setting ideal circumstances for sleep to occur,” said Michael Stevenson, a sleep specialist based in Mission Hills who treats patients, including Ebright, throughout the Los Angeles area. “You want to handle it like a manager of a baseball team does: You put the players in the right positions, and then just sit your waking self on the bench and let it happen.”

Several studies have shown that 30 to 40 minutes of daily exercise can help some people fall asleep more quickly and sleep more deeply. Doctors recommend working out in the morning, because exercising close to bedtime may interfere with sleep.

A hot bath before bed also may help, several experiments suggest. In one, researchers found elderly insomniacs who took a 30-minute bath in 105-degree water about an hour before hitting the sack slept more soundly than they had before.

Some doctors also recommend meditation, relaxation techniques or prayer: whatever quiets the mind and banishes the world’s current uncertainties.

“We are beginning to understand that sleep problems are neither completely mental, nor entirely physical,” Kushida said. “There always a little of both.”